From a recent article:
“Is It Executive Function Disorder (EFD) or ADHD?
Children and adults with executive function disorder (EFD) have problems with organizing and schedules. They may also have ADHD and/or learning disabilities, but not always — it’s a common misdiagnosis for those who are actually living with EFD.”
This is new hot topic. At least luke warm.Some are saying that ADD ADHD is getting misdiagnosed when it’s really executive dysfunction. But the symptoms of “Executive Function Disorder” listed below always seemed to me to just to be part of my ADD, although they’re not all part of the official definition and criteria.
” … deficiencies in planning, abstract thinking, flexibility and behavioral control”
Sound like anybody you know?
“In both children and adults with ADHD, an underlying executive dysfunction involving the prefrontal regions and other interconnected subcortical structures has been found.”
“Warning signs that a child may be having difficulty with executive function include trouble in:
- planning projects
- estimating how much time a project will take to complete
- telling stories (verbally or in writing)
- memorizing information
- initiating activities or tasks
- retaining information while doing something with it (for example, remembering a phone number while dialing)”
“…executive functions involve (at the very least):
- planning for the future and strategic thinking
- the ability to inhibit or delay responding
- initiating behavior, and
- shifting between activities flexibly”
Difficulty in being able to:
“Plan, Sequence, Prioritize, Organize, Initiate, Inhibit, Pace, Shift, Self-monitor, Emotional Control, Completing”
Sound like anybody you know?
Whichever of our brain networks and functions are off, they presumably produce all of these symptoms as well as the currently popular “benefits and gifts”.
My current best guess is that executive dysfunction is just another name for ADD AHD, maybe without the hyperactivity? Maybe the inattentive type?
doug
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We also have auditory processing disorder, dyscoordination, dyslexia,learning disorders and dystechnologica.
ADDadultstrategies 
Wow! Who knew there were so many offshoots, real or imagined, of ADHD. I had no idea.
I have the hyperactivity part and I have not outgrown it. I’m not bouncing off the walls – I’m more of a fidgeter. I sit on the edge of my seat and I’m up and down all the time. I can’t sit still. If I have to sit, I fidget. If I have to sit still and can’t fidget, I lose my mind!
I decided to get an official diagnosis so I have an appointment March 25th with a local psychiatrist.
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homey –
I’m like you, constant fidgeting. Bugs my wife. But I was never really hyper hyperactive, but I think the fidgeting qualifies.
Glad you’re getting an official diagnosis, think that will be helpful to you (hope your psychiatrist is knowledgeable, not all are).
Thank you for commenting.
Best wishes
Doug
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I hope my psychiatrist is knowledgeable, too. Supposedly ADD/ADHD is one of his specialties.
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homey – great. you’ve checked him out.
best wishes
doug
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To me, it makes great sense to deal with this as a part of the overall ADD/ADHD diagnosis. My therapist and I addressed this when we were working on my “Tools, strategies and tactics for living well with ADD/ADHD” “training” The “Executive Function” problems were addressed at the same time. I tend to combine this with the other oddities of ADD/ADHD. That was about 18 years ago and I still live well with my ADD Inattentive Type. No medications are taken for it because of other health issues. I actually have liked myself all my life with my ADD, but found that things got much more complicated with age and situations.
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Dianne – I agree, I also think it’s just part of the big picture. And as situations change, we often need to develop new strategies.
Thank you for commenting.
Doug
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On another tack Doug, have you reviewed Thomas E Brown’s ADHD model in which he highlights the main executive functions that are an issue in ADHD. I often find that that list is very helpful in drilling down to identify the key areas of dysfunction in an individual patient’s life.
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MB – I just checked Brown’s model, thank you for the referral. it covers a lot of our problems.
Thank you for commenting.
Doug
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Hi Doug,
It is instructive to review both the history of ADHD and the neurology of attention when considering this matter.
Back in the 1970’s ADHD used to go by the name “minimal brain dysfunction” and symptoms like dyslexia, sensory processing disorder, dyspraxia (developmental co-ordination disorder) and difficulties with 3 dimensional perception used to be considered part of the problem.
However, in time it was realised that these problems occur by themselves or also in association with other DSM categories, so they were split off into separate disorders.
However, the problem is that the ADHD label has now focussed attention entirely on the attention aspect of the problem and neglected the associations with other problems.
When I assess adult ADHD patients I always assess for all of these problems and as my findings are that the majority of adults have substantial issues with sensory processing and co-ordination.
None of these problems help our attentional function. In fact, a careful consideration of the problem of ADHD reveals that attention is the mediating process that stands between perceptual input and motor output. Additionally, more comprehensive analysis of ADHD patients reveals that multiple subcortical structures are involved in ADHD- especially the cerebellum and basal ganglia (both intimately involved in processing and refinement of movement) and the vestibular system. Close analysis reveals that it is the deficiency of cerebellar stimulatory input into the frontal lobe that is one of the key drivers of PFC underactivity rather than any primary defect in the PFC itself.
Dr John Ratey’s book “Spark” gives a particularly clear discussion of the association between movement and attention, but 2 more recent books go into much more detail: “Subcortical Structures and Cognition” and “ADHD as a Model of Brain- Behaviour Relationships”.
(Koziol et al ).
As for the name ADHD, Dr John Ratey suggests that the term “Attention Variability Disorder” is more appropriate, and I would agree that is more accurate.
The trick is that the names we use skew our assessment towards the process highlighted in the name. and also blunt our understanding by directing our attention away from the other aspects of the problem.
I think it is up to us clinicians to see the problem in its whole complexity and not just get locked into a black and white “It is ADHD or it is not” model– for the truth is that whether we choose to highlight the attention, the dyspraxia and eye movement instability, the sensory processing or the executive function facet of the problem, the usefulness of stimulant medication as part of the treatment plan is not diminished or refuted.
The real issue that we have to struggle with is the public confusion between the medically supervised use of stimulants to help patients function in reality more effectively versus drug abuse- which involves an escape from reality.
PS- sorry about thelong response– I guess i hyperfocussed 🙂
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MB-I certainly know about hyper focused. And agree that we may have to narrow focus and miss some of the other issues once we make the ADD ADHD diagnosis. and we have to address the public confusion and all the myths, misinformation, and falsehoods that are being promoted.
Thank you for your constructive comments. I may excerpt some of them. I assume PFC is pre-frontal cortex? wish I could find the time to read those books.
As always, thank you for commenting.
Doug
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Yes- correct re initials. I must show you my SPECT scan sometimes- it illustrates the connection between underpowered cerebellar afferent drive and underpowered contralateral PFC activity perfectly. Even better- the drop in right cerebellar activity is directly correlated to sitting posture while doing the STROOP test. Very instructive if one knows what to look for.
The reading is a pain- but I have had to do it- because my doctors could not provide me with enough information to get functional– so I have learned to do my own research.
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MB – I think this is over my head, but i’m getting the interesting idea that with one type of ADD ADHD we’re understimulated and another type we’re over stimulated? and the stimulation probably comes from the cerebellum and the Basal ganglia to the frontal lobe? and the pathway crosses over? Is that close?
thanks
Doug
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Hi Doug,
The “stimulation seeking” model of ADHD is rather outdated.
I know from my own experience that I meet formal diagnostic criteria for ADHD, developmental co-ordination disorder and sensory processing disorder.
The Wikipedia article on SPD is rather good really and it highlights symptoms of both undersensitivity to stimuli and oversensitivity.
My experience is that these sort of symptoms fluctuate- so I am usually quite insensitive to pain associated with chronic muscle tension , but will have times when I am very oversensitive to noise- and find cafes very hard to be in. (That is a pain- is really messes with socialising)
The work I am reading at the moment suggests that the basis for this dysfunctional sensitivity to sensory stimuli lies in the basal ganglia and their failure to recognise the appropriate context for amplifying or decreasing sensory awareness thresholds.
(This issue is closely tied in with the stress response- as one of the adaptive elements of the stress response is a drop in threshold of awareness to sensory stimuli (which is just what you need if you are in real danger)
Like many other ADHD individuals I have a degree of dysautonomia- and tend to slip into a high stress response quite easily. In my own case I am now clear that residual trauma responses underpin this dysautonomia- and ADHD individuals are far more prone to trauma than non ADHD individuals. I can’t comment authoritatively on all other ADHD individuals, but the patterns of dysautonomia and trauma are common in the ADHD patients I see. I would love to get some research done in this field- I have some promising preliminary data.
Now the cerebellar issue is to some extent separate from the basal ganglia issue- though they probably do feed back on each other. However in my own case I am well aware of the effect of a birth injury to my upper neck in driving cerebellar underfunction.
The cerebellar input crosses to the contralateral prefrontal cortex.
Put simply- as a result of the neck injury I am prone to spasm in the right suboccipital muscles, and the consequence of that spasm is a very substantial alteration in proprioceptive input to the right cerebellum- and an inhibitory post synaptic potential that feeds forward from the right cerebellum to the L prefrontal cortex.
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Thanks for the comments, MindBody! Do you have a citation for that Stroop paper? I’d love to read that. My background is in the research of cognitive control of memory/attention in the normal brain. I’ve just started looking into the ADHD literature because of my own brain, so I don’t know it well. I’m finding it really helpful to me personally, like Doug’s book has been, but also very interesting in terms of how it informs my own work. I’m going to go look up that model right now!
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Shannon- thank you for commenting. You can provide a lot of useful information, more experts, and most of us.
Best wishes
Doug
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didn’t read it carefully enough – “more expert than most of us”
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Hi Shannonell,
I don’t have references for the strop paper. What I was referring to was actually the result of my own SPECT scan. If you care to drop me a line via my blog I will email you and show you more detail and give you some further information about where to get more backing data.
The book ADHD as a model of brain behaviour relationships is probably the most useful one for your purposes. It places great emphasis on the role of cerebellum and basal ganglia in shaping cognition through selection of the items attended to (Basal Ganglia) and through modulation of the fluidity of the stream of thought (Cerebellum).
This is a major departure from the corticocentric models of cognitive control. I would be most interested to know if your research is taking you in that direction.
As a passing comment I have now been doing Tai Chi for a full year, and have had great improvements not only in pain, balance and co-ordination, but also in the fluidity of my thinking. It seems quite plain to me that there is a strong linkage between these improvements and my improved vestibular-cerebellar function.
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Thank you! The books are fantastic. I’m just about through with all of Brown’s stuff and only today got back here to see your reply. I also found the box I can check to be notified of replies by email. Ah. Organization.
ADHD as a model of brain behaviour relationships is my next stop. And I’ll be back to chat more about my own research path! Just on my way out now, got hyperfocused on catching up with Doug’s blog and am running late 😉
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MB, I was given the “Minimal Brain Dysfunction” diagnosis in 5th grade in 1954/55. My fifth grade teacher was a great help in getting me more “tuned in” in the classroom and my parents carried through at home. Because I did quite well in school and after I began working, I did not pursue a professional diagnosis until much later. In fact, I got my ADD diagnosis on my 50th birthday. I worked with a superior doctor and therapist and gained the ability to utilize tools, strategies, and tactics to smooth the bumpy areas of life. EF was simply part of that. My doctor and therapist mentioned it and both said that it was present in most cases of ADD that they had worked with. Perhaps most of the difficulty is created by attempting to separate all of the elements as opposed to working with all of it at the same time? I’m no expert, but that is my opinion…
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Dianne-makes sense to me. I was also rescued by a fifth grade teacher, although not about the ADD ADHD.
as always, thank you for commenting
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Hi Doug. It certainly is interesting, but I wonder. Correct me if I’m wrong, but the difference between ADD and ADHD is the hyperactive part; most adults don’t have the hyperactive part, supposedly because the adult developed brain acts differently under serotonin deprivation (the cause of the Syndrome/symptoms). So, why label it EFD from a certain point in age? That sounds nonsensical to me. Having said it about adults who saw their ADHD “develop into” ADD, here is my take on children who don’t even have ADHD, they “just” (ha!) have ADD. Why are we willing to label the symptoms as EFD, when the cause of ADD and ADHD is the lack of serotonine? What are “they” pointing out as the cause of EFD? I do think many children are being misdiagnosed, but ever since I started learning more about the whole deal, I realize that the brain won’t work properly on ritalin if it’s _already_ working properly, so wouldn’t these misdiangnoses be found out sooner? I’m going to stop asking questions now. As you can tell, I feel skeptical about this new label because I feel it’s just an attempt at getting new answers for what is almost a pandemic nowadays. There. That sentence was way more succint, but I saved you the trouble of asking me “what do you mean?”. I hope…. hehe
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RAM – I have a lot of questions and skepticism too.
Why do many adults outgrow the hyperactive part? maybe as our brains mature we have a little more self-control (. Maybe) , but why?
I’m not at all clear that serotonin lack is a part of the cause of ADD ADHD. It seems more related to dopamine and maybe norepinephrine?
I think part of your point, which I agree with, is if a child is misdiagnosed and put on Ritalin, there will not be any benefit.
as always, thank you for commenting.
Doug
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Yet another: why do some children not have the hyperactivity? My sister says I did (she told me for years I should have been diagnosed with ADHD as a child) but I don’t recall it like that. Plus, I had good grades. But I remember being absent minded even back then. And a couple of rage outbursts when frustrated.
On a side-note: I just realized that Executive Dysfunction sounds like a politically correct term for Attention deficit. Like vertically challenge for people with dwarfism.
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RAM- my guess is the main reason and your sister did not have the same genes, but there may be additional factors (epigenetics). I had good grades too- until college! WHAM!
yes, I think it’s a softening of the terminology, but unfortunately, it also fits into the current attack on us trying to undermine the concept of ADD ADHD.
Thank you for your good contributions.
Doug
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I think the label of EFD is not In place of ADHD. My understanding is that EFD refers to the set of EF deficits we are all familiar with. When it is identified in a child, they may have ADHD (either type), and/or learning disabilities. Rather than being about which type of ADHD a child has (or presence or absence of hyperactivity), it’s about identifying children who need assistance in schools for learning problems after EFD is identified, either because, for example:
A) their problems with executive function don’t respond to medication (e.g. maybe from an “minor” traumatic brain injury, and thus a result of physical changes in the brain that don’t respond to meds – like the breaking of axons that can happen in an acceleration/deceleration injury, or the crushing to death of neurons resulting from pressure from a closed head injury), or
B) because a learning problem remains although some EF problems are improved with medication – whether we understand why or not
Really it’s just about making sure kids who have EF problems, for WHATEVER reason, get the help they need to succeed academically if they are LD. This situation could easily happen if a child were diagnosed with ADHD without having a full psychoeducational assessment by a qualified person. Say a family doctor made an ADHD diagnosis, meds are tried, the kid still has trouble at school and the school responds by saying “Sorry, the kid is just a behaviour problem, or just has treatment resistant ADHD. No LD diagnosis? No funding for help.” And the child falls through the cracks.
Where I live, for example, TBIs are not considerd “exceptionalities” requiring scholastic support by the board of education. And all sorts of learning problems are overlooked by teachers because all they see is a behaviour problem. It often comes down to the education or attitude of the board or teacher involved, or how good/supported/numerous the psych staff of the board is. I think the article in question is speaking to an attempt to develop a beaurocratic procedure to get help for more kids who need it is all.
Here’s Russell Barkley’s opinion on it. His bias is that he, and his research program, are in the “ADHD is an executive function disorder” camp. He sees it now, unlike when he helped pioneer the field, as being all about self-regulation problems. This short interview explains the reasoning behind EFD work quite well. He also speaks to why, despite agreeing that ADHD is no longer the best name for us, changing it is not to be taken lightly or done until we are really sure we have new understanding:
http://voices.nationalgeographic.com/2013/02/24/revisiting-adhd-add-with-dr-russel-barkley-attention-deficit-disorder-or-executive-function-deficit-disorder/
I agree that the problematic bit is how scientific research is communicated to and used by the general public. The arguments behind cognition theories and research conclusions are complicated. People who do the research often don’t even articulate them well, or recognize all of the assumptions we’re making! Try reading a paper on free will by a modern, professional philosopher at philpapers.org if you never have — you’ll see what I mean! Cuz that’s the kind of theory behind research in control of attention, memory, decision-making…all the stuff we don’t understand neurologically yet in normal brains, let alone ADHD brains. Doesn’t translate easily into sound bites! It’s easier for people to grab onto tentative conclusions made by a good researcher and start throwing them around as fact “ADHD is or is not caused by this or that” when the truth is we don’t know yet.
Add that to the facts that:
-our knowledge and understanding of ADHD does, and will continue to change
– the research system requires scientists to “sell” their theories – it encourages us to construct the best narrative supporting our work we can in order to get funding
– scientific papers are facing the same “to curate or not to curate” problem as online news, novels, music and films…curation leads to pressure to sell your narrative and political gait-keeping to publication… no curation means proliferation of free, unreviewed online journals and having to wade through a lot of bad science to find the good stuff. And also the ability of people operating from a place of ignorance and prejudice to find “published” work which supports their positions.
I’ll try to be more brief in the future! This is just really close to my heart as a neophyte cognitive scientist who studies normal attention and is in the process of seeking a long missed ADHD diagnosis 🙂
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Sorry, forgot to log in. The big comment above on problems with school boards and research culture was from me!
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Anon/Shannon-
good to know it’s you! Looking forward to your future contributions.
Thanks
Doug
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anon- I like your approach – let’s just get the kid the help they need. Executive dysfunction certainly can be caused by other things, or can just be part of the ADD ADHD, in my opinion.
And we do need to try to get more clear, understandable information about ADD ADHD out. So you are helping with this.
Thank you for commenting.
Doug
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Hi shannon, first off: let me tell you I expressed myself incorrectly when I said the cause for ADD/ADHD is the lack of dopamin. I should’ve said it is the cause of the symptoms, as the lack of dopamin, like you and many researchers pointed out, can have different points of origin: slightly differently developed brain, minor pre-natal brain-damage, etc. Since ADD/ADHD responds well for the most part to medications that prevent the reabsoprtion of dopamin leaves us at a point beyond the fair assumptions and the throwing around of theories as facts. The differences on how well people react is a whole other subject, very likely dependent on the cause of the chemical imbalance that sticks us up with the symptoms.
Thanks for sharing the interview with Dr Barkley, I enjoyed it very much! However, I was referring to the person Doug quoted. When someone says “children and adults with EFD (…) may also have ADD/ADHD” this leaves absolutely no wiggle room, the guy is saying EFD is a thing on its own and possibly has ADD/ADHD as comorbidity factor. Funny enough, Dr Barkley DOES mention the notion of comorbidity but leaves Executive Function Disorder out of it: he clearly states at one point thaty EFD _is_ an alternative name for ADD/ADHD when prompted by the interviewer: “f you could re-lable the disorder what might you call it and why?” And well, sure enough, EFD will fit most of the symptoms (if not all) into a box and put a nice little bow on it, but in the end, I just see semantics here and that does nothing to convince me that we’re not just going for the new politically correct term.
Like you said very well, there is still a lot about the brain that we don’t know. But rather than trying to re-arrange the symptoms by phrasing it in newer and less threatening ways, we should be using the little we know as a stepping stone to further research. We _are_ using it as a stepping stone (a friend of mine tells me there are several studies going on at the hospital in Vienna) but we’re still not showing it – and while I agree with you that the way the information is being given to the public in general might not be the best, I still feel that the information isn’t even being brought out, it’s being turned into re-labeling and over-compartimentalizing of symptoms, which is not helpful to us and way off.
There is so much attention on ADD/ADHD nowadays that, aside from deficiencies in some institutions (which sadly will allways be the case), children are already getting a pretty targeted education (and I cannot stress enough that this has to be complemented by the parents at home, whether the children have ADD/ADHD or not. I get the bitter feeling that everything is expected from teachers and little from the parents). ADD/ADHD has also become such a stigma, because of all the eyes drawn to it, that there is the public doubt and critic of ADD/ADHD as a real syndrome. And that is also why this EFD is suddenly so suspicious in my eyes.
And as for being more brief…. ugh, right back atchya 😛 22 comments on this entry now, Doug. Hot topic indeed! 🙂
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RAM –
good comment.
Thanks
Doug
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